Journal of Contextual Behavioral Science 24 (2022) 171–178

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Assessing mindfulness and self-compassion facets as mediators of change in

patients with depressive, anxious and adjustment disorders: Secondary data
analysis of a randomized controlled trial
Yolanda López-del-Hoyo a, b, c, 1, Carlos Collado-Navarro a, d, 1, Adrián Pérez-Aranda c, e, g, *,
Javier García-Campayo a, b, c, Alba López-Montoyo a, b, c, Albert Feliu-Soler f, g, 2,
Juan V. Luciano f, g, 2, Jesus Montero-Marin g, h, 2
a
University of Zaragoza, Zaragoza, Spain
b
Primary Care Prevention and Health Promotion Research Network (RedIAPP), Zaragoza, Spain
c
Institute of Health Research of Aragon (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
d
University and Polytechnic La Fe Hospital, Valencia, Spain
e
Department of Basic, Developmental and Educational Psychology, Autonomous University of Barcelona, Cerdanyola Del Vallès, Spain
f
Department of Clinical & Health Psychology, Autonomous University of Barcelona, Cerdanyola Del Vallès, Spain
g
AGORA Research Group, Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, St. Boi de Llobregat, Spain
h
Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: Understanding how different psychotherapies produce their effect can lead to identifying mechanisms
Mindfulness of change that could be enhanced to produce better outcomes. This study aims at exploring the potential
Self-compassion mediating role of mindfulness and self-compassion facets in the effect of mindfulness-based stress reduction
ABCT
(MBSR) and attachment-based compassion therapy (ABCT) for reducing general affective distress in a sample of
MBSR
Path analysis
patients with anxiety, depressive, and/or adjustment disorders.
Method: Ninety patients participated in a randomized controlled trial with three assessment points: baseline,
posttreatment, and 6-months follow-up. The primary outcome was the ‘Depression, Anxiety, and Stress Scale’.
The ‘Five Facets of Mindfulness Questionnaire’, and the ‘Self-Compassion Scale’ were used for assessing the
corresponding facets as potential mediating variables. Path analysis models were computed, comparing each
treatment to the treated as usual control group.
Results and conclusion: The three facets of self-compassion were mediators of the effect of MBSR on affective
distress and, in the case of ABCT, ‘Self-kindness’ was the only mediator. Thus, self-compassion facets seem to be
potential mediators of MBSR; ‘Self-kindness’ would be the intermediary variable for ABCT’s effect. Nevertheless,
these results are exploratory and need to be replicated.

1. Introduction wave’ psychotherapies, e.g. mindfulness- and compassion-based pro­

grams among others, have proved efficacy for treating a wide range of
‘Third wave’ psychotherapies have been granted increasing attention conditions, including common psychiatric disorders such as depression,
in the last two decades. These interventions represent an innovation anxiety and adjustment disorders (Hofmann et al., 2010; Kirby et al.,
within the classic cognitive-behavioral therapy, as they focus on pro­ 2017; Vøllestad et al., 2012; Wilson et al., 2019).
moting mental wellbeing through the practice of mindfulness, compas­ The positive outcomes produced by ‘third wave’ interventions have
sion, acceptance, and spirituality (Jahoda et al., 2017). Different ‘third led some researchers to explore the underlying pathways of change of

* Corresponding author. Department of Basic Psychology, Autonomous University of Barcelona. Edifici B, 08193 Bellaterra, Cerdanyola del Vallès, Barcelona,
Spain.
E-mail address: aparanda@iisaragon.es (A. Pérez-Aranda).
1
Both authors contributed equally and should be considered co-first authors.
2
These authors contributed equally and should be considered co-senior authors.

https://doi.org/10.1016/j.jcbs.2022.05.007
Received 31 March 2022; Received in revised form 4 May 2022; Accepted 16 May 2022
Available online 18 May 2022
2212-1447/© 2022 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Y. López-del-Hoyo et al. Journal of Contextual Behavioral Science 24 (2022) 171–178

these psychotherapies. The systematic review and meta-analysis con­ among the most prevalent mental health problems, with rates between
ducted by Gu et al. (2015) concluded that mindfulness-based pro­ 3.6% and 4.4% in the general population (Lefstad, 2017; Vos et al.,
grammes, e.g. Mindfulness-Based Stress Reduction (MBSR), base their 2016). They have a significant negative impact on the individual’s
effect on impacting mechanistic variables such as cognitive and functionality and health-related quality of life (Bandelow & Michaelis,
emotional reactivity, mindfulness skills, rumination, worry, 2015; Richards, 2011), and present high incidence and recurrence rates
self-compassion, and psychological flexibility, although for some of (Scholten et al., 2013; Vos et al., 2016), which underlines the need of
these variables the evidence was preliminary. Another systematic re­ identifying the therapeutic mechanisms to potentiate the interventions’
view (Alsubaie et al., 2017) observed that the most consistent mediator efficacy.
of changes produced by mindfulness-based programs in different clinical Our exploratory hypotheses are that: 1) considering previous evi­
outcomes, including anxiety and depression, was the self-reported dence (Reese et al., 2015), the FFMQ subscales of ‘Acting with aware­
change in mindfulness skills. Regarding compassion-based programs, ness’, ‘Non-judging’, and ‘Non-reacting’, and the ‘Mindfulness’ subscale
the evidence is still scarce, although some possible mediators have been of the SCS –which mainly reflects non-reactivity and equanimity– are
identified: self-reassurance, positive and negative affect, and expected to be significant simple mediators of MBSR’s effect; and 2)
self-criticism, in the case of compassion-focused therapy (Sommers-S­ ABCT’s effect will be mediated by the three self-compassion pair of
pijkerman et al., 2018); and psychological flexibility, mindfulness skills, facets as well as the mindfulness facet of ‘Non-judging’, considering
and self-compassion, in the case of Attachment-Based Compassion some previous evidence regarding its relation with the self-compassion
Therapy (ABCT) (Montero-Marín et al., 2018; Montero-Marin et al., construct (Sedighimornani et al., 2019).
2020; Navarro-Gil et al., 2020).
Among the different ‘third wave’ process variables that have been 2. Method
reported as significant mediators, mindfulness skills and self-
compassion are particularly interesting, as each of them constitutes 2.1. Design
the core construct of a set of therapies (i.e. mindfulness-based, and
compassion-based programs), while the two of them have been identi­ This is a causal mediation analysis of a RCT in Spain (Collado-Na­
fied as potential mediators of different treatments such as MBSR or varro et al., 2021). This trial (registration number: NCT03425487) was a
ABCT. By taking part in these programs, the patients learn and apply the three-arm RCT in which 90 adult outpatients with anxiety, depressive,
concepts of mindfulness and compassion, although naturally MBSR is and/or adjustment disorders were recruited from three mental health
mainly focused on the practice of mindfulness exercises (e.g. body scan, units in Castellón (Spain) with three assessment points: baseline, post­
walking meditation, etc.), while ABCT grants special attention to treatment, and 6 months post randomization (follow-up). The partici­
attachment styles, compassion and equanimity. The two interventions, pants were randomized to treatment as usual (TAU), MBSR added to
added to treatment-as-usual (TAU), have proved to be more efficacious TAU, or ABCT added to TAU. The trial methods and interventions have
than TAU alone in a randomized controlled trial (RCT) for reducing been described in detail in the published protocol (Montero-Marin et al.,
general affective distress in a sample of adult outpatients who were 2019). The study was reported following the “Consolidated Standards of
diagnosed with anxiety, depressive and/or adjustment disorders, both Reporting Trials” guidelines (Moher et al., 2010).
posttreatment and after 6-months, yet no significant differences between
MBSR and ABCT were observed (Collado-Navarro et al., 2021). 2.2. Recruitment and inclusion criteria
In recent years, some authors have highlighted the importance of
elucidating how psychotherapies work in order to identify generic and Ninety adult outpatients were recruited from three mental health
specific mechanisms of change (Windgassen et al., 2016). In Collado-­ units in Castellón (Spain). This study represents a secondary analysis of
Navarro et al. (2021), the possible mediating role of mindfulness skills data from a RCT (Collado-Navarro et al., 2021). The inclusion criteria
and self-compassion as unidimensional variables was explored; both were 1) being aged between 18 and 75 years; 2) being diagnosed with
mediated MBSR’s effect on general affective distress, while only depressive and/or anxious disorder, or adjustment disorder with
self-compassion mediated the effect of ABCT. Nonetheless, there is solid depressive and/or anxious symptomatology (based on the DSM-5
evidence that indicates that both mindfulness skills and self-compassion criteria); 3) presenting mild or moderate severity according to the
are multi-dimensional constructs. Firstly, one of the most widely used clinical criteria; 4) having proficiency in Spanish; and 5) providing
models has identified up to five mindfulness facets (Baer et al., 2006): written informed consent. The following exclusion criteria were also
observing, describing, acting with awareness, non-judging of inner considered: 1) having done any type of meditative or contemplative
experience, and non-reactivity to inner experience. Self-compassion, on practice in the previous year; 2) presenting diagnosis of any disease that
its part, has been defined as composed of three pairs of opposite facets could affect the central nervous system, other psychiatric diagnoses or
(Neff, 2003): self-kindness (vs self-judgment), common humanity (vs acute psychiatric illnesses; or any medical condition or infectious or
isolation), and mindfulness (vs over-identification). Different studies degenerative disease that could affect mood; and 3) presenting delu­
have observed that the facets of mindfulness and self-compassion may sional ideas or hallucinations. Diagnoses were conducted by psychia­
have different impacts on mental health-related outcomes, such as trists or clinical psychologists using the Structured Clinical Interview for
depressive and anxiety symptoms or stress (Brown et al., 2015; Soysa & Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition
Wilcomb, 2015). Thus, the analyses regarding the possible mediators of Research Version (First et al., 2015).
MBSR and ABCT’s effects need to be expanded and include specific The sample size was calculated for the main analysis assuming a
mindfulness and self-compassion facets to deepen into the underlying large effect of ABCT vs. TAU and a small effect of MBSR vs. TAU in the
mechanisms of these psychotherapies; those mindfulness and primary outcome (i.e. general affective distress), and with an equal 1:1:1
self-compassion facets that are identified as strong mediators could be allocation rate, the size was estimated at 75 patients (25 per group), and
enhanced during the interventions through the practice of specific ex­ assuming a 15–20% attrition rate at follow-up, the total sample size
ercises that are able to enhance them. needed was established at 90 patients (30 per study arm). This was in
The present study aims at analyzing the potential mediating role of accordance with the recommendations for performing path analyses, as
the five mindfulness facets (Baer et al., 2008) and the self-compassion there was a minimum of 10 participants per variable (Nunnally &
pairs of facets (Germer & Neff, 2013) in the effect of MBSR and ABCT Bernstein, 1994).
for reducing general affective distress, next to depressive, anxious and
stress symptomatology, in a sample of adult outpatients who present
anxiety, depressive, and/or adjustment disorders. These disorders are

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2.3. Procedure and ethics psychometric properties (Cebolla et al., 2012). Cronbach’s alphas
showed good internal consistency in our sample at baseline
Participants were recruited consecutively in one wave from (‘Observing’: α = 0.77; ‘Describing’: α = 0.83; ‘Acting with awareness’:
September 2018 to February 2019. Those who fulfilled the inclusion α = 0.86; ‘Non-judging’: α = 0.88; ‘Non-reacting’: α = 0.71).
criteria and were interested in participating were referred to the The ‘Self-Compassion Scale’ (SCS; Neff, 2003)) is a 26-item ques­
research unit to be offered detailed information about the study. Written tionnaire designed to assess the components of self-compassion across
informed consent was obtained from all participants included in the three global facets: self-kindness, common humanity, and mindfulness
study before randomization, which was conducted by using a simple (Montero-Marin et al., 2018). This questionnaire uses a 5-point
random sequence remotely generated after baseline evaluation. In­ Likert-type scale, and although a total score can be calculated, the
dividuals were then assigned to an intervention (i.e., MBSR or ABCT, present study only uses the three subscales’ scores corresponding to the
both coadjutants to TAU) or to the control group (i.e., TAU). Once the three facets as potential mediators of the effect of the interventions. Each
interventions finished, all the participants were evaluated again, and a subscale score is computed by calculating the mean of subscale item
follow-up assessment was conducted 6 months after randomization. responses, and therefore ranges from 1 to 5, with higher scores indi­
Both interventions –whose detailed description can be found in the cating higher levels of self-compassion. The Spanish version of the SCS is
study protocol (Montero-Marin et al., 2019)– consisted of 8 weekly 2 h a valid and reliable instrument (Garcia-Campayo et al., 2014). Cron­
group sessions conducted by a trained clinical psychologist. MBSR pre­ bach’s alphas values at baseline in our sample were as follows: ‘Self-­
sents an educational orientation that includes teachings, informal ex­ kindness’: α = 0.75; ‘Common humanity’: α = 0.60; ‘Mindfulness’: α =
ercises, formal meditation (e.g., sitting meditation, body scan, walking 0.68.
meditation and gentle yoga), as well as individual and group dialogues
and inquiries about perceptions, habits, and patterns that may interfere
with mindfulness learning (Blacker et al., 2017, pp. 1–65). The MBSR 2.5. Data analyses
programme did not include the half-day retreat of mindfulness practice
that the original protocol usually contains due to schedule in­ Descriptive statistics were calculated to examine the characteristics
compatibility. On the other hand, ABCT, which is mainly based on the of the study sample. Bivariate correlations using Pearson’s coefficient
attachment theory (Fearon & Roisman, 2017), includes teachings, daily were then calculated between the baseline to follow-up changes in the
simple exercises, meditation training, visualisations, and specific prac­ study outcome (i.e., general affective distress) and the baseline to
tices oriented to augment the patients’ ability to be considerate and kind posttreatment changes in the mediational variables (i.e., mindfulness
towards themselves and their own experience –and more specifically and self-compassion facets) to identify potential mediators, following
their experience of suffering– and also others’ experience of suffering. the methods described in Hayes (2019) and Kazdin (2007).
This study was approved by the Ethics Committee of the General Simple mediation path analytic models were performed to test the
University Hospital of Castellón (7/2017). All procedures performed in study hypotheses (Lockhart et al., 2011; MacKinnon, 2008). The group
this study were in accordance with the criteria of the 1964 Declaration condition (‘MBSR + TAU’ vs ‘TAU’, or ‘ABCT + TAU’ vs ‘TAU’) was
of Helsinki, and the Declaration of Madrid of the World Psychiatric considered the independent variable, and the baseline to posttreatment
Association. The confidentiality of participants was protected by the change in the corresponding process variable was considered the po­
Spanish Organic Law on Protection of Personal Data and Guarantee of tential mediator. The baseline to follow-up change in the DASS-21 was
Digital Rights (3/2018, LOPD-GDD), and all relevant EU legislation on considered the outcome in all the models (see Fig. 1). Change scores
privacy and data protection. This trial was performed in compliance were used because they provide practical and comprehensible infor­
with the study registration (NCT03425487), as well as with good clinical mation that is very relevant for decision makers (Fu & Holmer, 2016),
practice guidelines (Vijayananthan & Nawawi, 2008). and they were considered appropriate after verifying that the data were
not skewed nor presented high kurtosis, and that baseline differences
2.4. Measures between groups were not statistically significant.
In the path analyses, only one mediator at a time was included
2.4.1. Primary outcome considering the number of participants and the number of parameters to
General affective distress was measured using the ‘Depression Anx­ be estimated in the mediational models. Separate mediation analyses
iety Stress Scales-21’ (DASS-21; Lovibond & Lovibond, 1995), which is a were conducted using maximum likelihood-based path analyses for
21-item self-report measure whose total score is considered a consistent continuous dependent variables. Regression coefficients (β) of boot­
measure of general affective distress (Zanon et al., 2020). It ranges from strapped indirect effects were estimated, as well as their 95% CIs based
0 to 63, with higher scores reflecting higher severity of affective distress on 10,000 bootstrap samples, considering a significant mediating effect
symptoms. The DASS-21 can also be divided in 3 subscales (i.e. when the referenced 95% CI does not include zero (Lockhart et al.,
Depression, Anxiety, and Stress), but only the total score was used in the 2011). Complete or partial mediation was established by analysing if the
present study. The DASS-21 has been validated in the Spanish popula­ direct path between the independent variable and the outcome after
tion, showing strong psychometric properties (Daza et al., 2002). controlling for the mediator (c’) was or not significant. The percentage
Cronbach’s alphas showed good-to-excellent internal consistency values of mediating effects regarding the total direct effects (c) for each po­
at baseline in our sample (α = 0.94). tential mediator was independently estimated. The percentage of vari­
ance in the outcome that was explained by the corresponding mediating
2.4.2. Mechanistic measures
Mindfulness has been conceptualized as a multidimensional
construct, composed by the facets of observing, describing, acting with
awareness, non-judging, and non-reacting to the inner experience. These
facets were assessed in the present study by means of the ‘Five Facet
Mindfulness Questionnaire’ (FFMQ; Baer et al., 2006), a self-report
questionnaire which contains 39 items that are answered on a 5-point
Likert-type scale. In the present study only the subscales’ scores were
used; facet scores range from 8 to 40 (except for non-reacting, which
ranges from 7 to 35), with higher scores indicating higher levels of
mindfulness skills. The Spanish version of the FFMQ has shown good Fig. 1. Generic example of a simple mediational model.

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model was established by means of determination coefficients (R2). An 3.2. Mindfulness-based stress reduction: correlations and path analysis
alpha level of 0.05 was set, using a two-tailed test. The statistical
packages used for the present exploratory study were SPSS v27.0 and The bivariate correlations conducted using the MBSR and TAU
Mplus v8.4. groups (complete cases analysis sample; n = 46) revealed that the
baseline to follow-up changes in the DASS-21 total score showed sig­
3. Results nificant negative associations with the baseline to posttreatment
changes in the mindfulness facet of ‘Acting with awareness’ and in the
3.1. Baseline sociodemographic and clinical characteristics three self-compassion subscales (see Table 2).
The results of the path analyses for the MBSR vs TAU comparison are
Table 1 summarizes the main sociodemographic characteristics of detailed in Table 3. Three of the four models that were tested reflected a
our sample, comparing the three study arms. Most patients were middle- significant mediation effect. That was the case of the three self-
aged women; around two thirds were married, and the vast majority had compassion subscales: ‘Self-kindness’, ‘Common Humanity’ and ‘Mind­
at least completed primary education; almost 40% of the sample had fulness’; all of them were mediators of the effect of the intervention on
paid employment at baseline, and around 50% earned less than the the outcome (‘Self-kindness’: β = − 2.51, 95% CI -10.81 to − 0.78;
national minimum wage (NMW). Most participants had been under ‘Common Humanity’: β = − 4.62, 95% CI -12.33 to − 0.29; ‘Mindfulness’:
treatment (i.e. psychotherapy, psychiatric, or both) for more than a year, β = − 2.82, 95% CI -7.52 to − 0.35), with small to medium effects, while
and the three study arms included patients who were diagnosed with the direct effect of the intervention after controlling for the mediator
depression, anxiety disorder, adjustment disorder, or mixed. No signif­ was not significant in any case (p = .242, p = .271, and p = .125,
icant differences were found for the general sociodemographic charac­ respectively).
teristics between the three study arms.
3.3. Attachment-based compassion therapy: correlations and path
analysis
Table 1
Baseline characteristics of patients by treatment group. The bivariate correlations conducted using the ABCT and TAU
ABCT + TAU MBSR + TAU TAU (n = p groups (complete cases analysis sample; n = 47) revealed that the
(n = 30) (n = 30) 30) baseline to follow-up changes in the DASS-21 total score showed sig­
Sociodemographic data nificant negative associations with the baseline to posttreatment
Age, mean (SD) 46.83 (10.84) 44.30 (12.50) 47.90 .462 changes in the FFMQ ‘Observing’ subscale and the SCS ‘Self-kindness’
(10.99) subscale. These correlational results are detailed in Table 2.
Gender (n females, %) 27 (90.0) 25 (83.3) 26 (86.7) .925 Direct and indirect paths are presented in Table 4. The model in
Marital status, n (%) .770
Single 6 (20.0) 3 (10.0) 4 (13.3)
which the SCS ‘Self-kindness’ subscale was included as mediator resul­
Married/ relationship 20 (66.7) 22 (73.3) 19 (63.4) ted significant (β = − 5.11, 95% CI -10.97 to − 1.74), with small to
Separated/ divorced 3 (10.0) 5 (16.7) 6 (20.0) medium effects, and the direct effect of the independent variable on the
Widowed 1 (3.3) 0 (0.0) 1 (3.3) outcome after controlling for the mediator was not significant (p =
Place of residence, n (%)
.541). The mindfulness facet of ‘Observing’ did not result as a significant
Own home 22 (73.3) 22 (73.3) 20 (66.7) .833
Relative’s home 3 (10.0) 4 (13.3) 5 (16.7) mediator.
Neighbor/friend’s home 2 (6.7) 0 (0.0) 1 (3.3)
Other 3 (10.0) 4 (13.3) 4 (13.3) 4. Discussion
Education, n (%)
No studies 2 (6.7) 1 (3.3) 0 (0.0) .407
Primary studies 11 (36.7) 8 (26.7) 15 (50.0) The present study aimed at exploring the potential mediating role of
Secondary studies 12 (40.0) 13 (43.3) 8 (26.7) mindfulness and self-compassion facets in the effect of MBSR and ABCT,
University 5 (16.7) 8 (26.7) 7 (23.3) both added to TAU, for reducing general affective distress in a sample of
Employment, n (%) Spanish outpatients diagnosed with anxiety, depressive, and/or
Unemployed 3 (10.0) 2 (6.7) 4 (13.4) .253
Employed 11 (36.7) 14 (46.5) 10 (33.3)
Home duties 8 (26.6) 2 (6.7) 6 (20.0) Table 2
Student 2 (6.7) 2 (6.7) 0 (0.0) Pearson’s bivariate correlations between baseline to follow-up changes in the
Sick leave 2 (6.7) 5 (16.7) 1 (3.3) outcomes (i.e. DASS-21 and subscales) and the baseline to posttreatment
Retired 4 (13.3) 5 (16.7) 9 (30.0) changes in process variables (i.e. FFMQ’s and SCS’s subscales).
Economic level, n (%)
≤ NMW 15 (50.0) 15 (50.0) 13 (43.3) .518 ΔDASS-21 Total score
1–2 x NMW 11 (36.7) 6 (20.0) 11 (36.7)
MBSR vs TAU ABCT vs TAU
2–4 x NMW 3 (10.0) 8 (26.7) 6 (20.0)
FFMQ
>4 x NMW 1 (3.3) 1 (3.3) 0 (0.0)
ΔFFMQ Observing -.25 (.100) -.33 (.022)*
Time on treatment, n (%) .822
ΔFFMQ Describing -.17 (.255) -.20 (.175)
0–2 months 4 (13.3) 6 (20.0) 5 (16.7)
ΔFFMQ Acting with awareness -.37 (.011)* -.12 (.414)
2 months to 1 year 6 (20.0) 7 (23.3) 9 (30.0)
ΔFFMQ Non judging -.23 (.120) -.14 (.349)
more than 1 year 20 (66.7) 17 (58.6) 16 (53.3)
ΔFFMQ Non reacting -.28 (.073) -.14 (.354)
Type of treatment, n (%)
SCS
Psychological 10 (33.3) 14 (46.5) 12 (40.0) .702
ΔSCS Self-kindness -.42 (.004)* -.40 (.005)*
Psychiatric 10 (33.3) 6 (20.2) 10 (33.3)
ΔSCS Humanity -.40 (.005)* -.25 (.087)
Psychological and 10 (33.3) 10 (33.3) 8 (26.7)
ΔSCS Mindfulness -.38 (.009)* -.22 (.130)
Psychiatric
Diagnosis, n (%) Note: p values are between brackets; *p ≤ .05. Correlations were computed with
Depressive disorder 7 (23.3) 5 (16.7) 9 (30.0) .260 complete cases (i.e. patients who had been assessed in the three evaluation
Anxiety disorder 9 (30.0) 14 (46.5) 7 (23.3) periods); n = 46 (MBSR vs TAU), n = 47 (ABCT vs TAU). Higher scores indicate
Adjustment disorder 9 (30.0) 8 (26.7) 13 (43.3)
greater general distress (DASS-21), higher levels of mindfulness (FFMQ), and
Mixed 5 (16.7) 3 (10.0) 1 (3.3)
higher levels of self-compassion in SCS total score, self-kindness, common hu­
Note: ABCT: attachment-based compassion therapy. MBSR: mindfulness-based manity, and mindfulness subscales, while lower levels of self-compassion in self-
stress reduction. TAU: treatment as usual. NWM: National minimum wage. judging, isolation, and over-identification subscales.

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Table 3
Direct and Bootstrap indirect effects in the mediational models of MBSR vs TAU.
DIRECT EFFECTS INDIRECT EFFECTS
2
Outcome and mediators (R ) path Coeff. SE P path Boot. (% of total effects) SE 95% CI

DASS-21

FFMQ Acting with awareness (.21) a1 5.97 1.81 .001 a1 b1 − 4.08 (45%) 2.60 − 10.49 to 0.02
b1 − 0.68 0.35 .052
c’ − 5.00 4.27 .242
SCS Self-kindness (.16) a1 0.52 0.18 .005 a1 b1 ¡4.36 (48%) 2.52 ¡10.81 to -0.78
b1 − 8.40 2.99 .005
c’ − 4.72 4.29 .271
SCS Common humanity (.21) a1 0.73 0.22 .001 a1 b1 ¡4.62 (51%) 2.92 ¡12.33 to -0.38
b1 − 6.33 3.04 .037
c’ − 4.46 5.25 .964
SCS Mindfulness (.09) a1 0.39 0.20 .047 a1 b1 ¡2.82 (31%) 1.73 ¡7.52 to -0.35
b1 − 7.19 2.30 .002
c’ − 6.26 4.08 .125

Note: DASS-21: ‘Depression, Anxiety, and Stress Scales’. FFMQ: ‘Five Facets of Mindfulness Questionnaire’. SCS: ‘Self-Compassion Scale’. SE: Standard error. A1: direct
path between the independent variable and the mediator. B1: direct path between the mediator and the outcome. C’: direct path between the independent variable and
the outcome. c: total direct effects. A1b1: indirect path. DASS-21’s c: β = − 9.08, SE = 4.28, p = .034.

Table 4
Direct and Bootstrap indirect effects in the mediational models of ABCT vs TAU.
DIRECT EFFECTS INDIRECT EFFECTS

Outcome and mediators (R2) path Coeff. SE P path Boot. (% of total effects) SE 95% CI

DASS-21

FFMQ Observing (.21) a1 5.29 1.51 <.001 a1 b1 − 3.42 (46%) 2.26 − 8.84 to 0.01
b1 − 0.65 0.37 .082
c’ − 4.02 4.42 .364
SCS Self-kindness (.26) a1 0.67 0.17 <.001 a1 b1 ¡5.11 (69%) 2.27 ¡10.97 to -1.74
b1 − 7.65 2.72 .005
c’ − 2.32 3.80 .541

Note: DASS-21: ‘Depression, Anxiety, and Stress Scales’. FFMQ: ‘Five Facets of Mindfulness Questionnaire’. SCS: ‘Self-Compassion Scale’. SE: Standard error. A1: direct
path between the independent variable and the mediator. B1: direct path between the mediator and the outcome. C’: direct path between the independent variable and
the outcome. c: total direct effects. A1b1: indirect path. DASS-21’s c: β = − 7.43, SE = 3.87, p = .054.

adjustment disorders. meditation, an exercise that implies holding in mind a particular person
For what concerns to MBSR, previous studies had identified various and repeatedly wishing for them to be well and happy. The metta
potential mediators; specifically, cognitive and emotional reactivity had meditation has proved to have a significant impact on different out­
presented solid evidence, while mindfulness skills, rumination, and comes such as happiness and compassionate love, reductions in avoid­
worry had showed ‘moderate but consistent’ evidence; on the other ance and revenge, and reductions on the depression, anxiety and stress
hand, self-compassion and psychological flexibility were only supported subscales (Alba, 2013). The metta meditation is often presented in the
by insufficient and preliminary results (Gu et al., 2015). According to final sessions of the intervention and is not considered essential for
our findings, the self-compassion facets of ‘Self-kindness’, ‘Common MBSR. However, considering our findings, this exercise –and others
Humanity’, and ‘Mindfulness’ seem to be significant mediators of the which could enhance self-compassion– should be granted a relevant role
effect of MBSR on general affective distress. Each of these effects rep­ in the intervention.
resents a complete mediation, as the direct path between the indepen­ ABCT’s potential mechanisms, on the other hand, have just been
dent variable (i.e. the treatment arm) and the outcome is not statistically recently started to be explored. While Montero-Marín et al. (2018) found
significant after controlling for the mediator, but the indirect path (i.e. that psychological flexibility, defined as the ability to function in the
the one that connects with the mediator) is (Pardo & Román, 2013). present moment without needless defense, or either persisting with or
Nonetheless, this could be due to a lack of statistical power, as for the changing behavior in the pursuit of goals (S. C. Hayes et al., 2006), was a
relatively small sample size used for the analyses. significant mediator of the change observed in functional impairment in
Our exploratory results suggest that, in our sample, MBSR would fibromyalgia patients, more recent studies (Navarro-Gil et al., 2020;
successfully teach patients how to be kinder and warmer towards their Collado-Navarro et al., 2021) identified self-compassion as a significant
own suffering (i.e. ‘Self-kindness’), how to recognize that suffering and mediator of the effects of ABCT in general population participants, along
personal inadequacy is part of the shared human experience (i.e. with mindfulness in patients with anxious, depressive, and/or adjust­
‘Common Humanity’), and how to take a balanced approach to their ment disorders. Montero-Marin et al. (2020), on the other hand, found
negative emotions so that feelings are neither suppressed nor exagger­ that the self-compassion facet of ‘Common humanity’ –and not the total
ated (i.e. ‘Mindfulness’) (Neff, 2003), and each of these learnings would score nor the other facets– was the significant mediator of the changes
be in turn responsible of the significant reduction of affective distress. produced by ABCT in anxiety and depression for a sample of fibromy­
The capacity of MBSR to impact on the facets of self-compassion has algia patients. Our results suggest that one self-compassion facet is
been documented (Birnie et al., 2010; Raab et al., 2015; Shapiro et al., particularly relevant as an intermediary of the improvements produced
2005). This intervention not only focuses on practicing mindfulness but by ABCT in our sample: ‘self-kindness’, which was a significant mediator
also introduces the concept of compassion and practices it through of the changes produced in general affective distress. As stated previ­
meditation, with exercises such as the loving-kindness (or metta) ously, self-kindness implies being warm and understanding toward

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ourselves when we suffer, fail, or feel inadequate, rather than ignoring unreliable measures might yield non-significant results in RCTs. In our
our pain or flagellating ourselves with self-criticism (Montero-Marín case, we must acknowledge that some of the study variables (e.g.,
et al., 2016; Neff, 2003), and is both explicitly and implicitly addressed ‘common humanity’) had a scarce reliability value (coefficient alpha
in ABCT through the practice of different exercises such as ‘becoming below .70). In addition, the exploratory nature of the present study may
our own attachment figure’ or ‘the compassionate action’ (García-­ imply the possibility of type I and II errors due to multiple comparisons,
Campayo et al., 2016). Based on our results, ABCT might improve the which were not corrected considering the exploratory nature of this
ability of the patients for being warm and understanding to their own work. Single-mediator models do not allow to test multiple-mediator
suffering, and that ‒probably along with other learnings‒ would imply theories because they do not assess the independent contribution of
significant improvements in general affective distress. each targeted mediator to the explanation to the intervention effect.
Thus, our two hypotheses were only partially corroborated by our Therefore, future adequately powered research should use this type of
results, as some of the expected mediators did not show significant ef­ models. Finally, it needs to be reflected that the MBSR programme did
fects. Surprisingly, few FFMQ subscales (baseline to posttreatment not include the half-day retreat of mindfulness practice that the original
change) presented a significant correlation with the outcome (baseline protocol contains due to schedule incompatibility; however, the inter­
to follow-up change). It was hypothesized that three mindfulness facets vention resulted efficacious (Collado-Navarro et al., 2021), and its un­
would be significant mediators of MBSR’s effect, considering that they derlying mechanisms should not deviate from the original protocol.
had been associated with behavioral inhibition systems and emotion In conclusion, our findings suggest that self-compassion facets (i.e.,
dysregulation (Reese et al., 2015): ‘Acting with awareness’, which refers ‘self-kindness’, ‘common humanity’, and ‘mindfulness’) are potential
to the ability to focus on one’s activities in the here and now, ‘Non-­ significant mediators of the effect of MBSR on affective distress. On the
judging’, which refers to taking a non-evaluative stance toward thoughts other hand, ABCT’s effect on affective distress would be mediated by
and feelings, and ‘Non-reacting’, which is the tendency to allow ‘self-kindness’. Future studies should focus on replicating our results
thoughts and feelings to come and go, without getting caught up in or using larger samples which could make it possible to conduct multiple
carried away by these (Baer et al., 2006). In addition, ‘Non-judging’ was mediation analyses. In this regard, the results of the present study could
also expected to be a significant mediator of ABCT’s, due to its reported be used for informing and estimating the possible sample size required
association to self-compassion (Sedighimornani et al., 2019). Nonethe­ for performing the corresponding analyses in studies involving patients
less, none of these mindfulness facets resulted significant mediators in with anxiety, depressive, and adjustment disorders. On the other hand,
any case. This would imply that, although the interventions produced more ‘third wave’ process variables should be included in the analyses,
significant improvements in some mindfulness facets compared to TAU, as some of them have already been identified as potential mediators in
these learnings were not responsible of reducing affective distress, and previous studies, yet conducted with different clinical samples, such as
maybe other mechanistic variables that were not assessed in the present psychological flexibility (Ciarrochi et al., 2010; Montero-Marín et al.,
study (e.g. psychological flexibility, attachment styles) could be playing 2018; Pérez-Aranda et al., 2019; Wicksell et al., 2010), and changes of
a significant role. Another possible explanation is that, as observed by attachment style, which seems to represent a key element of ABCT. The
Collado-Navarro et al. (2021), the real mediator of the improvements ABCT intervention attempts to release the insecure attachment style that
would not be a particular facet of mindfulness, but a global, unidi­ some patients manifest by facilitating the disengagement of
mensional mindfulness trait, as measured by the FFMQ total score. self-centered judgmental and critical attitudes, which are commonly
Nevertheless, as stated previously, it seems likely that the relatively associated with psychopathological processes, and promoting a more
small sample used in this study could be undermining the statistical secure attachment style that is characterized by a higher degree of
power of our analyses. self-compassion (Montero-Marin et al., 2020). Therefore, future studies
However, the present work adds to previous research (Roca et al., should also analyze the potential mediating role of achieving a signifi­
2021; Sevel et al., 2020) indicating that mindfulness- and cant change in the attachment style, as this could be the main inter­
compassion-based programs might operate through a combination of mediary variable of clinical changes produced by the ABCT program.
shared (e.g., self-kindness), and specific mechanisms. In this regard, it
needs to be added that the exploratory mediation analyses comparing Author contributions
the two active interventions (i.e. MBSR and ABCT) did not yield any
significant mediator, which was considered expectable after observing YLDH: Conceptualization, Resources, Software, Data curation,
no significant differences between MBSR’s and ABCT’s effects on the Project administration. CCN: Conceptualization, Visualization, Imple­
mechanistic variables and also on the general affective distress outcome mentation, Writing – review & editing. APA: Visualization, Methodol­
in the RCT (Collado-Navarro et al., 2021). ogy, Formal analysis, Writing – original draft. JGC: Conceptualization,
As we have mentioned, the main limitation of this study is the Resources, Supervision. ALM: Visualization, Resources, Implementa­
relatively small sample that was used for calculating the bivariate cor­ tion. AFS: Visualization, Writing – review & editing. JVL: Visualization,
relations and, subsequently, the path analyses. This sample size was Writing – review & editing. JMM: Conceptualization, Methodology,
originally estimated for the RCT main analysis, but not for the secondary Software, Data curation, Formal analysis, Visualization, Supervision,
explorations. The RCT design of the study offers a rigorous methodology Writing – original draft, Writing – review & editing.
that minimizes the risks of reporting spurious therapeutic effects (Lil­
ienfeld et al., 2014), but such a small number of participants did not
Ethics approval
allow the performance of path analyses with more than one mediator
(multiple mediation), which would also have been undoubtedly inter­
This study was approved by the Ethics Committee of the General
esting considering that the outcome presented more than one potential
University Hospital of Castellón (7/2017).
mediator. In addition, our results are based on self-reported measures,
although the DASS-21 is generally considered a consistent measure of
affective distress (Zanon et al., 2020). Also, more assessments (e.g., Funding
during the intervention) could have allowed analyses on how the
changes in the potential mediators affected the outcomes in the post­ None.
treatment timepoint. In this line, future studies might use ecological
momentary assessment to find out whether changes in hypothesized Data availability statement
mediators along therapy sessions predict the trajectory and evolution of
study outcomes at follow-up. On the other hand, it is well known that Data is available upon reasonable request.

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Y. López-del-Hoyo et al. Journal of Contextual Behavioral Science 24 (2022) 171–178

Declaration of competing interest wellbeing? A systematic review and meta-analysis of mediation studies. Clinical
Psychology Review, 37, 1–12. https://doi.org/10.1016/j.cpr.2015.01.006
Hayes, A. F. (2019). Introduction to Mediation, Moderation, and Conditional Process Analysis
JGC is the coauthor of the ABCT program handbook and receives (Vol. 2507). New York, NY: Guilford Press.
royalties. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and
commitment therapy: Model, processes and outcomes. Behaviour Research and
Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006
Acknowledgements Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-
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APA has a ‘Sara Borrell’ contract from the Instituto de Salud Carlos III Consulting and Clinical Psychology, 78(2), 169–183. https://doi.org/10.1037/
a0018555
(ISCIII; CD20/00181). AFS acknowledges the funding from the Serra Jahoda, A., Stenfert Kroese, B., Pert, C., Jahoda, A., Stenfert Kroese, B., & Pert, C. (2017).
Húnter program (Generalitat de Catalunya; reference number UAB-LE- Mindfulness and third wave therapies. In Cognitive Behaviour Therapy for People with
8015). JMM has a “Miguel Servet” contract from the ISCIII (CP21/ Intellectual Disabilities (pp. 181–212). Palgrave Macmillan UK. https://doi.org/
10.1057/978-1-137-47854-2_9.
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